Dialectical Behavior Therapy for Binge-Eating Disorder

Susan Wiser
Santa Clara University
Ä

Christy F. Telch
Stanford University School of Medicine

Binge-eating episodes have alternately been described as stemming from

strict dieting behaviors driven by overvalued ideas of weight and shape, or
as arising from problematic interpersonal experiences. A third way of con-
ceptualizing an eating binge is as a maladaptive emotion-regulation strat-
egy, suggesting that facilitating more adaptive and effective affect regulation
capacities may be a useful treatment. Dialectical Behavior Therapy (DBT),
a treatment aimed at increasing emotion regulation skill, is currently being
adapted for use with a binge-eating disorder population. Assumptions
underlying the treatment, methods in treatment delivery, and goals of the
treatment package are discussed. A pilot study currently underway of
group DBT therapy for individuals with Binge-Eating Disorder is
described. © 1999 John Wiley & Sons, Inc. J Clin Psychol 55: 755–
768, 1999.

An eating binge is described as a lack of experienced control over the consumption of an

objectively large quantity of food in a discrete period of time. Binge-Eating Disorder, a
recently proposed diagnostic category appearing in DSM-IV as a “criteria set . . . pro-
vided for further study,” is characterized by eating binges that cause marked distress, are
not followed by compensatory behaviors, and occur at least twice a week for a period of
at least six months (American Psychiatric Association, 1994). In addition to those that
meet the proposed criteria for Binge-Eating Disorder, individuals diagnosed with Bulimia
Nervosa and Anorexia Nervosa, Binge-Purge type, struggle with binge-eating episodes.

The research described in this article was supported in part by National Institute of Health Grant MH54641–02
awarded to Christy F. Telch, Ph.D.
We wish to thank Marsha Linehan, Ph.D., and W. Stewart Agras, M.D., for their invaluable consultation,
Shireen Rizvi, B.A., for her reliable project management, and all of the participating clients for their efforts and
their wisdom.
Correspondence and requests for reprints should be sent to Susan Wiser, Ph.D., 219 Bannan Hall, Santa Clara
University, Santa Clara, CA 95053. Correspondence concerning the Stanford DBT for BED program should be
addressed to Christy F. Telch. Ph.D., Department of Psychiatry, 401 Quarry Road, Stanford, CA 94305–5722.

JCLP/In Session: Psychotherapy in Practice, Vol. 55(6), 755–768 (1999)

© 1999 John Wiley & Sons, Inc. CCC 0021-9762/99/060755-14
756 JCLP/In Session, June 1999

COGNITIVE–BEHAVIORAL AND INTERPERSONAL MODELS

Etiological models highlight a variety of cognitive, behavioral, interpersonal, and affec-
tive risk factors implicated in binge-eating episodes (Fairburn & Wilson, 1993; Heather-
ton & Baumeister, 1991; Heatherton & Polivy, 1992; Heatherton, Polivy, & Herman,
1991; Striegel-Moore, 1993). Cognitive risk factors include the internalization of the
“thin ideal,” dichotomous thought patterns pertaining to food and eating, body dissatis-
faction, and unrealistic standards and expectations of self. Behavioral risks pertain to
food restrictions and restraints. Interpersonal factors include isolation, interpersonal skill
deficits, and dissatisfaction with interpersonal relations. Affective risk factors include
low self-esteem, anxiety, and dysphoria. Conceptual models that describe more than one
pathway to disordered eating have been proposed; these models tend to highlight the role
of restrained eating and negative affect.
Cognitive–behavioral and interpersonal treatments focus on several of these risk
areas in an effort to interrupt the pathway to binge eating, and have proven to be moder-
ately efficacious (Agras, 1993). Cognitive–behavioral theory highlights the interplay of
overvalued ideas regarding weight and shape, as well as strict dieting practices that leave
one vulnerable to binge eating. Cognitive–behavioral treatment focuses on these behav-
ioral and cognitive factors by prescribing regular meals and snacks in order to normalize
eating patterns and reduce urges to binge, conducting exposure to “feared” foods, and
changing distorted and dichotomous thinking about weight, body image, and food. In
contrast, interpersonal theories conceptualize binge eating as symptomatic of distur-
bances in interpersonal functioning, and treatment focuses on identifying and problem-
solving interpersonal difficulties in four domains: (i) grief, (ii) interpersonal disputes,
(iii) role transitions, or (iv) interpersonal deficits.
Standard cognitive–behavioral treatment is based on the model that binge eating is
primarily a problem of distorted ideas about weight, shape, and restrictive eating; inter-
personal therapy, on the other hand, assumes that binge eating is principally a problem of
interpersonal functioning. The binge behavior itself, however, has been described fre-
quently as a method to regulate distressing emotions. Distressing emotional states may be
triggered by a multitude of internal or external events that may be either related or unrelated
to weight and body concerns. Loneliness, conflicts with friends or family, job stress, and
comparisons between one’s own body type and the media ideal are all commonly cited
triggers of such emotional distress. Irrespective of the particular trigger—be it cognitive
or interpersonal—if the individual feels unable to regulate the emotional state, then binge
eating may be used in order to dull, dampen, or avoid it. Theory regarding the function of
the binge suggests that such bingeing may serve to distract from, or reduce the intensity
of, upsetting emotions, and/or it may divert attention from meanings and ideas that evoke
distress. Because negative affect is “the most cited instigator of a binge episode” (Polivy
& Herman, 1993, pp. 179), another way to conceptualize the binge-eating problem behav-
ior is as a problem not of eating (as the cognitive-behavioral framework suggests), and
not of interpersonal functioning (as the interpersonal framework suggests), but one pri-
marily of affect regulation.

AN AFFECT-REGULATION MODEL
An affect regulation model postulates that the prototypic origin of a binge is with the
threat or presence of an unwelcome emotional experience. This experience might be
generated from within, as in the woman who reads a fashion magazine, compares her
body unfavorably with the models depicted, and feels ashamed, unworthy, and disgusted
with herself. The emotions might be prompted by circumstance, as with an individual
 DBT for Binge-Eating Disorder 757

who is home alone on a Saturday night and feels extremely lonely. And emotions might
be triggered by interaction with others, as in the case of a woman who is yelled at by her
boss or scolded by her spouse.
Because emotions involve the total response system of an individual (cognitive,
physiological, affective), these experiences may also include painful personal meanings
that further exacerbate the intensity of the distress. One woman may believe that no one
will ever find her physically appealing and that she will therefore be destined to perpetual
rejection and loneliness. Another individual may think he deserves to be friendless because
he is so boring. A third individual may believe that her anger at her boss or spouse
indicates that she is a “bad” individual. Such personal meanings or beliefs tend to exac-
erbate emotional distress by intensifying it and leading to other, secondary, emotional
experiences.
Thus women who binge may have deficits in adaptive emotion regulation skills:
Once the emotional experience threatens to emerge into awareness, or is consciously
perceived, the individual frantically searches to minimize or end it. Women who binge
have learned that binge eating can be a quick fix that numbs painful emotions (Arnow,
Kennedy, & Agras, 1992). During the binge episode, attention is narrowed, and cognitive
faculties are directed away from awareness of emotion and personal meanings and toward
concrete immediate food-related issues. Individuals often describe a pleasurable sense of
rebellion prior to and/or during a binge episode, which might serve somewhat to coun-
terbalance whatever unpleasant emotions were present. The binge in this sense “works,”
which makes it increasingly likely that binge eating will be used to escape emotional
distress, particularly in the absence of alternative, adaptive emotion-regulation skills.
Many individuals struggling with binge eating behavior indeed cite the distracting
and emotion-dampening functions of the binge as centrally linked to their use of it. If the
binge itself serves as an individual’s most accessible and effective means to modulate
affect, then treatment aimed at providing alternative, more functional affect regulation
strategies should prove quite useful. In essence, if the affect regulation strategy of binge
eating could be functionally replaced with equally accessible, effective, but adaptive
emotion regulation strategies, then binge-eating behavior should become unnecessary,
and ultimately cease.

DIALECTICAL BEHAVIOR THERAPY: EMOTION REGULATION TREATMENT

Dialectical behavior therapy (DBT) is the empirically validated treatment of choice for
individuals with borderline personality disorder (Linehan, 1998). It is a comprehensive
long-term treatment aimed at reducing life-threatening and quality-of-life–impairing behav-
iors in this population. It conceptualizes characteristic pathological behavior such as
self-mutilation and anger outbursts as faulty attempts at affect regulation, and teaches
clients new, more functional ways to modulate their emotional experience. DBT is pri-
marily a treatment of adaptive affect regulation, and thus its strategies and techniques
could prove useful in binge eating.
We believe that binge-eating behavior often functions in a fashion similar to the
dangerous behavior characteristically emitted by individuals with borderline personality
disorder. In both cases, emotional experience arises (or threatens to arise), and is expe-
rienced as intolerable. In the absence of adaptive and effective methods to cope with the
emotional experience, maladaptive coping behaviors are enlisted to modulate the emo-
tion. For those with borderline pathology, the maladaptive behaviors that function to
regulate emotion may be self-mutilation, suicidal gestures, or acts of aggression toward
others. For those with binge-eating difficulties, an attempt to regulate intolerable affect
would typically be through use of an eating binge.
758 JCLP/In Session, June 1999

DBT skills training is comprised of four overarching treatment components: (i) mind-
fulness skills, (ii) distress tolerance, (iii) emotion regulation, and (iv) interpersonal effec-
tiveness. The central goals of mindfulness are to decrease judgment of self and others and
to increase awareness and acceptance of experience. Aims of distress tolerance include
increased tolerance of painful affect and decreased maladaptive behavioral responses to
distress. Objectives of emotion regulation skills include reduced emotional vulnerability
and enhanced ability to alter a current emotional state. The focus of interpersonal effec-
tiveness skills include clarification of interpersonal priorities and objectives, and increased
appropriate assertiveness.
Together, the skills of mindfulness, distress tolerance, emotion regulation, and inter-
personal effectiveness aim to supply the client with borderline pathology with a multi-
tude of adaptive emotion and interpersonal management strategies that may replace current
maladaptive ones and increase effective goal attainment. Clients use “diary cards” to
track and record daily emotional experiences, behaviors, and their daily practice of the
DBT skills. Written “behavioral chain analyses” are also employed to help clients uncover
the internal and external factors that lead to their maladaptive behavioral responses. The
chain analyses are explored collaboratively, and ways that new DBT skills could be
enlisted to avert maladaptive behavioral responses are examined. Readers are referred to
the DBT text and Skills Training Manual for complete descriptions of the DBT treatment
elements (Linehan 1993a; Linehan 1993b).

DBT FOR THE TREATMENT OF BINGE EATING

Currently, research aimed at adapting DBT principles and coping skills for the group
treatment of women meeting criteria for Binge-Eating Disorder is underway in the Depart-
ment of Psychiatry at Stanford University. In order to examine the efficacy of a treatment
that specifically deals with affect regulation deficits, DBT group therapy for Binge-
Eating Disorder teaches mindfulness, distress tolerance, and emotion regulation skills.
The interpersonal effectiveness components of the overall DBT package are not included,
both to enable brevity of treatment and to allow for comparisons of this affect regulation
treatment with other interpersonally focused therapies for eating dysfunction. In addition
to affording greater clarity regarding the efficacy of specific change agents, focusing on
these three components also allows completed treatments to be delivered in a 20-session
format. Comprehensive DBT includes both weekly group therapy “skills training” in
which the large package of DBT skills are systematically taught, and weekly individual
therapy in which daily difficulties are examined and the transfer of newly acquired skills
to daily life situations is facilitated. The adaptation of DBT for the binge-eating popula-
tion that is described below combines the skills training components and the application-
of-skills-to-daily-life components in a weekly group therapy format.
Obtaining commitment to treatment goals and to therapy methods is a crucial first
step in treatment. In the Stanford Binge-Eating Disorder study, clients spend time in
pretreatment interviews and during much of the first two treatment sessions discussing
these issues. As in DBT treatment for Borderline Personality Disorder, treatment goals
are arranged hierarchically by severity of the behavior. Following is the list of treatment
goals used in the DBT for Binge-Eating Disorder treatment study, in order of decreasing
severity:

1. Stop any behavior that interferes with treatment.

2. Stop binge eating.
 DBT for Binge-Eating Disorder 759

3. Eliminate mindless eating (eating episodes where a lack of control over consump-
tion is not experienced, but eating is accompanied by minimal awareness—such
as when one eats a bag of chips while watching TV without really noticing the
food or the eating).
4. decrease cravings, urges, and preoccupation with food.
5. Decrease “capitulating” (giving up and acting as if there is no option other than to
binge eat.
6. Decrease “apparently irrelevant behaviors” (behaviors engaged in as if irrelevant
and harmless when in fact they make binge eating more likely—such as buying a
10-pound box of your favorite binge food to have in the house “in case friends
stop by”).

The most severe behavior that each client engaged in that week is discussed in the
group session.
DBT for Binge-Eating Disorder group treatment sessions are two hours long. The
first hour of group focuses on homework review. During this hour, each group member
reports on her practice of skills during the last week (recorded on diary cards that are
collected each week); also during this hour facilitators and other group members help
examine any binge eating or other maladaptive eating episodes that occurred (described
in minute detail by clients on “behavior chain analysis” forms that are collected each
week). In the second hour, group members learn new skills through didactic presentations
and experiential exercises. Treatment components are described briefly below along with
clinical examples that demonstrate the use of DBT skills to discontinue binge-eating
behavior in a group therapy modality. This study is currently in progress, and releases to
reproduce actual clinical material are unavailable; the therapy dialogues presented in this
article are therefore representative but hypothetical.

Mindfulness Skills

One core assumption in the affect regulation model of binge eating is that binge eating is
used to circumvent awareness of emotional experience. Mindfulness meditation, by con-
trast, teaches an acute, but particular, awareness of emotional as well as all other expe-
riences. Through mindfulness meditation, clients are taught an awareness of experience
that is in-the-moment, nonjudgmental, and single minded; such awareness is often quite
distinct from clients’ more typical highly critical, judgmental, past-focused and future-
focused attentional center. Through the use of mindfulness skills, clients paradoxically
gain more direct contact with their immediate experience while simultaneously achieving
some distance from it. They turn awareness toward occurring experience, but stay par-
tially separate from it by learning to observe their experience, as one might observe
clouds moving across a sky; they are fully present with experience, but are also outside
observing it. Such an observational and nonjudgmental stance is designed to reduce sec-
ondary emotional responses such as guilt and shame that are typically fueled by judg-
ment. By practicing mindfulness, clients learn that emotional experience is transitory and
represents only a part of their existing reality in any given moment. Learning to simply
observe or witness and then nonjudgmentally describe sensations, emotions, and impulses
helps clients to avoid overidentifying with and magnifying these sensations, and thereby
affords greater impulse control.
Clients are oriented to the use of mindfulness skills in the following manner:
760 JCLP/In Session, June 1999

therapist: We know that the most important thing for you to accomplish is to stop binge
eating, and that binge eating occurs in the context of strong emotions. Right now,
your binge eating and your emotions are tightly linked in an almost knee-jerk reac-
tive manner. At this point, binge eating is such an overlearned response that you may
not even be aware of the emotions that set it off. In order to break this automatic
association between emotions and eating, we will teach mindfulness skills. Mindful-
ness skills are awareness skills. Mindfulness is a quality of attention that has no
preferences—it shines on all experiences equally, without judgment. Mindfulness
accepts present experience as one of constant change. All experiences arise and pass
away like waves on the sea, and mindfulness accepts this on a moment-to-moment
basis. There is no attempt to control or fix the present moment or what happens next.

One reason that mindfulness, or nonjudgmental awareness, may be useful to clients

is that judgment tends to be associated with secondary emotional reactions (that is, shame
or guilt); these secondary emotional reactions intensify and complicate already-existing
distress. Achieving skill in mindfulness means decreasing judgment. The presence of
critical judgment is often seen to underlie the difference between the difficult but toler-
able experience of emotional “pain” and the far less tolerable experience described as
emotional “suffering.” Another reason that mindfulness may be useful to binge-eating
clients is that it requires an open and receptive stance toward experience rather than
avoidance, which characterizes a binge. Because avoidance is incongruous with mind-
fulness (much like anxiety and relaxation are incongruous), binge eating in the context of
mindfulness cannot occur.
Following is an example of a client using the “conveyer belt” mindfulness exercise
to circumvent an imminent binge episode:

client 1 (sharing with the group during homework review): As I left work, all I could
think about was all of the bakeries that I could hit on the way home. I had that
all-revved-up, wild, frantic kind of feeling where I can’t think of anything but getting
to those bakeries and eating as many pastries as I can. The notebook that I keep all of
my treatment handouts and homeworks in was in the front seat [of my car], and as I
sat down I flung it to the other side of the car; I didn’t even want to think about not
having my binge. As I sat in traffic, I thought about my commitment to the therapy,
and to all of you here in the group, and of having to tell you that I’d binged—and I
decided to try the new skill we learned last week. I drove to a park near to my
workplace and did the conveyer-belt exercise. First I imagined a conveyer belt, and
putting all of my experience onto the belt. Then I closed my eyes and just stepped
back inside myself and watched. I just observed and described, with as little judg-
ment as I could, what came down the belt. First I noticed feeling revved up, and said
to myself: “That’s a revved up feeling coming by.” Then I noticed thinking this is
stupid, and I said to myself: “Okay, that was a judgment about this exercise, that it is
stupid.” It was interesting—as I stayed and watched what came down the conveyer
belt; I didn’t hold onto anything, nor did I try to push anything away. I simply
observed each thing, and labeled for myself whether it was a thought, a feeling, an
impulse, or a sensation. I noticed a lot of thoughts and impulses about wanting to eat,
and about wanting to leave the park; I just said to myself: “Ah, there’s a desire to
have a pastry; there’s an impulse to get up and get back in the car.” But over time I
began to observe feelings of sadness and disappointment that I sensed in the center of
my chest. I just stayed and watched as these feelings kept coming down the conveyer
belt, and noted “That’s a sensation of tightness in my chest” and “That’s sadness
 DBT for Binge-Eating Disorder 761

that’s coming down now.” Although it wasn’t pleasant, I also noticed a feeling of
calmness that came down the conveyer belt the longer I did the exercise. After about
twenty minutes, I stopped the exercise, decided that I wanted to visit a friend, and
went over there. We ended up having dinner together and I didn’t binge at all.

In addition to offering a new way to experience feelings, thoughts, and impulses, the
six mindfulness skills (Observe, Describe, Participate, Nonjudgmentally, One-mindfully,
and Effectively; Linehan 1993b) offer a new way to eat. “Mindful eating” is a skill in
which one brings full, present-oriented, moment-to-moment, single-minded, nonjudg-
mental awareness to eating. In group, clients are taught the skill of mindful eating expe-
rientially. They are each given a few raisins. They use mindfulness skills to become
aware of the sight, smell, and texture of the raisins as they hold them in their palms. They
turn the raisins over in their hands, noticing the feel of the raisin skins, the way the light
rests in the nooks and crannies, and how the shapes of the raisins differ. They eventually
place the raisins in their mouths and turn their full awareness to the feel, taste, shape, and
texture of the raisins as the raisins rest on their tongues. As the clients begin to chew
mindfully, they notice shapes, transformations in texture, shifts in sweetness, changes in
their saliva, sounds of their teeth, and many other aspects of the raisin-eating experience.
Many clients are shocked to find the depth of experience available in the simple act of
eating two to three raisins, and many note that such mindful eating stands in diametrical
contrast to their typical manner of eating. Other mindfulness skills such as “urge surfing”
(riding out an urge to binge using mindfulness skills instead of responding to the urge by
eating) and “alternate rebellion” (using mindfulness skills to find constructive, non-eating–
related ways to act out feelings of rebelliousness) have been added to this treatment to
adapt it more effectively to the binge-eating population.
These mindfulness skills, as described in the standard DBT manual, are taught in
sessions 3 to 5 and are reviewed in session 13. For these and all other skills taught, clients
are provided with an educational orientation to the skills, and are led through a variety of
in-session experiential practice exercises; further, the clients are instructed to conduct
daily between-sessions skills practices, and are provided with both standard skills hand-
outs and homework sheets, as well as additional ones developed specifically for the
Stanford project . Our clinical impression is that the more clients practice the skills, the
more successful they appear in their efforts to curb binge eating and other dysfunctional
eating behaviors.

Emotion Regulation Skills

Sessions 6 to 12 are devoted to teaching emotion regulation skills, which help clients to
(I) understand and identify the various parts of an emotional response, (ii) determine
functions of emotions, (iii) reduce vulnerability to uncomfortable emotions, (iv) build
positive emotional experiences, and (v) change emotional states. Clients are oriented in
the following way:

therapist: Many women with binge-eating difficulties fall into the trap of labeling their
emotions as the problem. Emotions certainly are problematic when you don’t have
effective ways to cope with them—ways that both work and promote your sense of
well-being. But the emotion regulation module will demonstrate that emotions needn’t
necessarily be problematic. It’s like thirst—although it’s uncomfortable to feel thirsty,
it’s only problematic if you don’t have methods to quench the thirst effectively.
762 JCLP/In Session, June 1999

Emotion regulation skills won’t help you to eliminate unpleasant emotions; that would
be as dangerous as eliminating thirst. Emotion regulation training will, however,
help you to reduce emotional suffering; reduce the intensity, duration, and frequency
of some strong emotion states; and increase your experience of positive emotions.
We will explore together why you have emotions, what they do for you, and how you
can use them to your advantage. We will also teach you a variety of methods to
manage emotional states so that the occurrence of positive emotional experiences
can be increased. The skills will help you to “work with” your feelings—to alter
them in ways that are helpful to you—rather than “work against” your feelings by
avoiding, criticizing, or suppressing them. You’ll see how the nonjudgmental aware-
ness that you’ve learned in the Mindfulness component will help you to experience
your emotions in a new way. You’ll use the emotion regulation strategies—in place
of binge eating—to regulate your emotional experiences.

During the seven sessions of emotion regulation training, psychoeducation and group
discussion about emotions abound. Clients explore personal and cultural myths about
emotions. They identify triggers to emotions, uncover the relationship between their inter-
pretations of events and consequent emotional responses, and study the various bodily
changes that take place during emotions. Clients also learn about the motivational action
impulses that coincide with strong emotions; they then learn to label emotional experi-
ence clearly, and examine the adaptive functions of emotions. Following is a typical
discussion about the functions of emotions and how those functions can be maximized.

therapist (speaking from a playful, challenging stance): So, what good are emotions
anyway?
client 1 (laughing): They’re no good, of course! I wish I could get rid of them altogether!
(Laughter and agreement from most group members.)
therapist: Well, that’s an understandable attitude, given how hard they’ve been to deal
with! But come on . . . they’re here for a reason, right? Does anyone have any ideas
on some things they might be trying to do for you?
client 2: I don’t know—maybe try to get me to do something about a situation?
client 3: They let me know how I really feel about things.
therapist: Absolutely. Do others agree? That your emotional responses are self-
validating in a way—they give you information about a situation that’s happening,
and they also motivate you to respond to it? (Agreement from various group mem-
bers.) What about communicating to others? Do you find that your emotions are a
way to send a message to others about how they’re affecting you?
client 4: I guess they do, whether we intend them to or not. I find that some emotions—
like anger—communicate more clearly than do others. For instance, I often feel
really sad and hurt, but no one notices. It makes it much worse, and it’s ridiculous to
have to go tap someone on the shoulder and tell them, “Hey, I’m sad, pay some
attention to me.”
therapist: That brings up a really important point. The message that our emotions want
to communicate doesn’t always get received by the people around us. It’s probably
the case that sometimes people aren’t paying good attention. And it’s probably the
case that sometimes we send the message in “code,” and then other people misinter-
pret it. (Group members voice agreement that others often misinterpret them.) The
code that might confuse the message could be facial expressions, tones of voice, and
body language that aren’t easily understandable. It might have been really important
in the past, like when you were kids, to not let people know how you were really
 DBT for Binge-Eating Disorder 763

feeling. It’s not uncommon for people to keep feelings private by masking facial
expressions and voice quality when the environment doesn’t support those feelings.
And it’s awfully important to figure out the code that our bodies might be using so
that we can try to “decode” our communications and increase the likelihood that oth-
ers will receive our emotion messages. Do you want to talk some more about that?

In addition to reeducation about emotions and effective emotional expression, a sec-

ond key aspect of the emotion regulation training is reducing emotional vulnerability.
This is achieved by (i) decreasing behavior patterns that leave clients vulnerable to neg-
ative emotion (such as not getting adequate sleep or using drugs and alcohol), and (ii)
increasing behavior patterns that make them more resilient in the face of negative emo-
tion (such as engaging in pleasurable activities and getting regular moderate exercise).
Clients are also encouraged to engage in activities that evoke a sense of mastery, and to
clarify short-term and long-term goals that could contribute to a more satisfying and
fulfilling life.
Finally, in emotion regulation skills training, clients learn ways to alter what they
perceive to be unjustified current emotional experiences. Unjustified emotions are those
perceived by the client to be out of proportion to the triggering event and/or interfere
significantly with their quality of life. One example would be intense rage that is expe-
rienced when a typically reliable friend is required to stay late at work and then cancels a
dinner date. Another example might be the significant anxiety that arises in response to
an invitation to attend a party full of people that the client would like to get to know. A
third would be the deep shame that is felt after making an inconsequential mistake at
work.
There is no judgment placed on these emotional responses; however, if these responses
are deemed by the client to be more intense than the situation warrants, and/or serve
detrimental rather than facilitative functions as defined by their own values and goals,
then they are perceived to be candidates for change. The following clinical example
demonstrates the emotion regulation skill of “acting opposite to emotion,” which is a key
strategy for addressing these unjustified emotional responses. The idea behind this strat-
egy is that acting in accordance with the action urge associated with the emotion (for
example, running away when one feels scared or aggressing physically when one feels
angry) strengthens the emotion. The skill involves doing the opposite of what the emotion
urges you to do, in order to change the emotion over the long term. The tactic required is
simply to observe and describe the emotion and the concordant action impulse, and then
to determine rationally what behavior would be the opposite to what the felt emotions
seemed to demand.

client: I was so angry with Jamie for canceling our dinner date at the last minute! I
know her boss was forcing her to work all night, but it seems like I’m always the one
getting left behind. I had been looking forward to it all day because I really needed to
talk about some things—I was really counting on her input. I realize that my rage
wasn’t fair—it wasn’t her fault and she felt really bad about it, but I was just so angry
nonetheless. And we all know how good eating feels when you’re in a rage.
therapist: So that was really disappointing and maddening. Were you able to use some
of the skills to deal with those feelings at that moment?
client: Well, of course my first impulse was to binge all night—if I couldn’t have my
nice evening out, at least I could binge to make myself feel better. What I did do,
though, was use Mindfulness Skills to just stay with my feelings for a while. I became
aware of my anger, and a desire to deal with it without binge eating. I decided to use
764 JCLP/In Session, June 1999

Opposite-to-Emotion Action, because although my rage felt true, I also knew at the
same time that the feelings weren’t really fair to her—she didn’t deserve that kind of
anger even though I was feeling it. The action urge associated with the rage “wanted”
me to call her at work, scream at her, and tell her how much she let me down and how
unfair it was. So, the opposite action was, first, to not call while I was in the intense
rage, and second, to empathize with her perspective and reach out to her in kindness.
When I was feeling a bit less angry, I called her at home and left a message on her
machine saying that I really missed her, that I understood that she had to stay at work,
and that I looked forward to a raincheck. I also sympathized with her workload, and
told her to call if she needed anything. When I got off the phone, I felt remarkably
better. It’s like the anger changed over to pride and self-satisfaction, and I didn’t have
the urge to binge anymore.

Distress Tolerance Skills

Distress tolerance teaches how to endure highly distressing situations that are not ame-
nable to change, without making those situations worse by impulsive maladaptive react-
ing. These skills are taught in sessions 14 to 18. The premise underlying the distress
tolerance module is that distressing situations are an unavoidable part of human life and
that learning to survive them effectively is crucial. The package of cognitive, behavioral,
and spiritual/meditative techniques taught in this module help individuals to distract
from, mollify, or open themselves in acceptance to high levels of pain and distress with-
out responding maladaptively. For clients addressing binge eating, this means responding
without binge eating or engaging in any other dysfunctional eating behavior. The basic
idea is to get through or tolerate the situations and feelings without making matters worse
by reacting with binge eating.
During these five sessions of distress tolerance, clients engage in significant discus-
sion about the inevitability of distress in life and the wisdom of surviving it effectively
without making it worse. The truism that trying to avoid unavoidable emotional experi-
ences actually tends to exacerbate emotion intensity is underscored.
Clients are taught two classes of distress tolerance techniques: crisis survival strat-
egies and acceptance strategies. The crisis survival strategies are made up of a host of
cognitive and behavioral techniques that function to divert attention temporarily away
from, or somewhat attenuate, the high level of distress experienced. The acceptance strat-
egies, by contrast, aid clients to calmly embrace and tolerate the distressing experience as
it is, without attempting to alter or avoid it in any way.
The purpose of distress tolerance might be explained to clients as follows:

client: I binged today, and I’m not sure if I won’t again tonight. I have this terrible
situation at work and I’ve been completely frantic all day. I finally submitted the
report that I’ve been working on for weeks, but I won’t find out if it’s acceptable for
three days. My job hangs in the balance. It’s driving me crazy with anxiety. Now, in
addition to the anxiety, I’m also hating myself for relapsing with the binge. I just
want to crawl out of my skin.
therapist: I can see why you’re so anxious. You’re sitting at the edge of a cliff, waiting
in terrified anticipation to find out if you’re going to get shoved off. I imagine that
you’re not feeling at your luckiest today, but, as luck would have it, we are about to
begin teaching distress tolerance skills, which are going to help. Now, I caution you:
These skills won’t take you off the cliff to safety. I don’t know if anything could do
 DBT for Binge-Eating Disorder 765

that. What they can offer is help in surviving your three days on the cliff edge with-
out creating even more pain for yourself, like the binge did today.

The crisis survival strategies include the following:

1. Distraction techniques (for example, doing hobbies; writing letters; visiting with
friends; taking walks; making downward comparisons with others who are coping
less well or are in more dire circumstances; creating alternate emotional states by
reading particular books and watching specific movies).
2. Self-soothing strategies (for example, lighting candles, watching stars at night,
listening to tapes of nature sounds, smelling fresh flowers, mindfully tasting a
strong herb tea, petting the cat, snuggling with a favorite soft blanket).
3. Improving-the-moment methods (for example, finding meaning in the distressing
situation; being one’s own cheerleader; engaging in spiritual thoughts or prayer).
4. Learning to evaluate the pros and cons of tolerating and not tolerating current
distress.

A companion to the above distress tolerance crisis survival strategies are the distress
tolerance acceptance strategies; ironically, these are probably the most difficult ones for
clients to accept. Acceptance strategies encourage clients to oppose their natural impulse
to fight emotionally or behaviorally against the inescapable situation that they find them-
selves in by psychologically embracing the moment with open hearts and minds, just as
the moment truly is, replete with pain. Acceptance implies neither approval nor passivity;
it does, however, signify a deep accepting of the reality of the situation as it is. Accep-
tance skills include a variety of breathing, half-smiling, and awareness exercises. The
assumption underpinning these methods is that when a painful situation is unavoidable,
efforts at avoidance often transform the pain of the situation into the even less tolerable
experience of suffering. Returning to the above example of the client who must wait for
three days to find out if she retains her job or will be fired:

client: So I handed in the report, and then couldn’t think of anything except the ice
cream shop. I went there, had a large sundae, and then headed on to the fast-food
place, where I got three orders of french fries—ate them in about one minute—and
then stopped off at the drugstore and bought a half-dozen candy bars. I ate five of
them. I almost didn’t come because I felt so nauseous.
therapist: Excellent that you did come. How did you make that happen?
client: I’m not sure. Just didn’t let myself think about not coming, I guess. As soon as
I thought about staying home, I just pushed the thought away, and told myself that at
least I could do one good thing today and get myself to group. I also knew that it
would get my mind off things for at least a few hours.
therapist: Sounds like you used several distress tolerance skills there. You distracted
yourself with the “pushing thoughts away” technique, and you did a quick “pros and
cons” of coming versus not coming to group. You also are using the group itself as a
distracting activity, which we are happy to provide! (With a light-hearted, humorous
tone) And you thought you hadn’t done anything much good today . . . typical!
Now, we do need to figure out together how that binge happened? Because it
doesn’t sound like you feel better for having had it, or that it’s helping you deal with
this situation. So let’s figure that out, and then maybe get some more distress toler-
ance ideas from the group. Sitting on the edge of that cliff for the next three days is
going to be a serious challenge.
766 JCLP/In Session, June 1999

This interchange highlights several general DBT treatment strategies. One is that all
attempts at coping need to be highlighted. Here, despite an impulse to avoid coming to
treatment, the client shows up; this action is illuminated, and the specific skills that she
used to make it happen are made manifest. Second is that therapists continually send the
dialectical message that (i) no binge eating is acceptable and, (ii) if an episode of binge
eating or any other maladaptive eating occurs, therapists are wholly accepting and work
collaboratively with the client to determine why it occurred and how it can be prevented
in the future.
In figuring out why the binge episode occurred, a moment-to-moment analysis would
be conducted. In this analysis, clients identify many factors related to the binge episode,
including: vulnerability factors (for instance, inadequate sleep, high levels of stress);
event triggers (such as, in this case, the boss telling the client that she might lose her job
if the report was substandard); links leading from the trigger to the binge (that is, all of
the thoughts, feelings, actions, and impulses that led to the binge); and the aftereffects of
the binge (such as feeling nauseous, self-hatred). Clients would then explore what skills
could have been used to interrupt the chain of thoughts, feelings, impulses, and behaviors
that led to the binge.

client 1: Here is one critical link—I felt so anxious, and then had a thought that I
couldn’t handle it. That really sent my anxiety skyrocketing. I could have used
some skills right there. In response to that thought, I might have used mindfulness
skills to notice and label the thought as a thought, rather than believing it to be a
fact. I also might have used the distress tolerance skill of “improving the moment”
by encouraging myself with memories of difficult things that I have handled well
in the past, and with my belief that the report was quite good and would likely
be acceptable.
client 2: Maybe you could find some meaning in the situation. Like you, I also expect
to, and therefore often do, crumble under stress. Maybe a meaning could be that the
universe is going to try to teach you that you’re stronger than you think. That even if
the worst happens and you lose the job, you can still keep it together, deal with it, and
find something else to do.
client 3: You could also try some acceptance skills, like doing half-smiling, and follow-
the-breath exercises. Trying to feel some acceptance of the fact that you’re smack
dab in the middle of an awful situation that you can’t do anything about could
help.
client 4: I don’t know about right at that moment, but in the next three days, I might use
the distraction technique of contributing something to others. The local public radio
station is taking volunteers for their fund drive, the homeless shelter downtown takes
meal prep volunteers—and there’s always that ad in the paper for reading books to
kids in the hospital. It might make you feel good, take your mind off the report, and
probably help you keep perspective on it all.
therapist: I thought you identified a real key link, and I liked the skills that you say
could have come in right then. What do you think about these other ideas to deal with
the next few days?
client: I like some of them. I guess, most of all—I think if I stay active and do distrac-
tion skills I’ll be in the best shape. When I leave tonight, I’m going to call some
people and make firm plans to meet for coffees, movies, and lunches—and I do think
I will call that hospital ad and see if I can spend some time each day for the next few
days reading to the kids. That sounds like it would really calm me down and take my
mind off of myself and my worries.
 DBT for Binge-Eating Disorder 767

Effectiveness—or doing what works—is a key concept in DBT treatment. In prac-

tice, there is a strong expectation that all of the skills presented will be learned and
practiced by clients: Because it’s not possible for clients to predict in advance which
strategies will work best for them in given situations, they can be expected to run through
the repertoire of presented skills. In this regard, there is no requirement that any partic-
ular coping skill be used to circumvent binges. Clients are actively encouraged to practice
and use as many skills as possible so that they have a wide repertoire to draw from. One
individual may use only three of the entire package of skills to regulate affect and stop
binge eating, whereas another client may use fifteen of the skills. We are invested less in
the particulars of skill choice and more in clients’ ability—and in their recognition of this
ability—to use skills adaptively and effectively.
The last two sessions in the treatment are reserved for review and strengthening of all
of the coping skills. Our research on DBT for Binge-Eating Disorder is in progress;
bearing the still-developing state of our information base in mind, we note, however, that
preliminary observations are encouraging, and suggest that the DBT skills can be learned
and applied to stop binge eating. Additionally, our clinical impression is that the treat-
ment is credible and well accepted by clients. We look forward with excited anticipation
to confirming or disconfirming these observations statistically when the current project is
completed. An unexpected and particularly rewarding occurrence has been the spontane-
ous declarations by many of the group members that they use the new skills not only in
place of binge eating, but also more generally for self- and relational enhancement. It will
be very interesting to assess the extent to which these coping skills remain regular parts
of these women’s lives in the planned post-therapy follow-up assessments.

CONCLUSIONS
Throughout this article, we have suggested a conceptualization of binge eating as a mal-
adaptive, yet momentarily effective, method of regulating affect and dampening distress.
Given this notion, we find it sensible to provide treatment that assists clients to learn and
practice methods of adaptive affect regulation that may replace their current maladaptive
binge-eating strategy. DBT, adapted from its use with individuals who have Borderline
Personality Disorder, offers a broad and comprehensive package of skills that does just
this. Through teaching clients DBT Mindfulness Skills, Emotion Regulation Skills, and
Distress Tolerance Skills, we aim to provide clients with a multitude of affect regulation
options to use in moments when the urge to binge eat arises.

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